North Mountain Medical and Rehabilitation Center

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Based on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure adequate skin assessments and monitoring were completed for newly identified skin conditions for one resident (#155) according to facility policy and professional standards. The deficient practice could lead to care team members not being aware of the status of a resident’s skin condition.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that medications were administered within ordered parameters and in accordance with accepted standards of practice for one of five sampled residents (Resident #10) who were found to have unnecessary medications. The deficient practice had the potential to cause adverse drug effects and place residents at risk for harm from unnecessary medication that was not clinically indicated at the time of administration.

Number of residents sampled:Â 154Number of residents cited:Â 26Based on observation, interview, review of clinical record, and review of facility policy and procedure, facility failed to ensure that residents with an atypical rash received appropriate treatment, isolation, and infection control measures for 24 residents (#155, #36, #50, #185, #186, #41, #51, #53, #54, #55, #85, #188, #99, #180, #189, #106, #9, #123, #190, #150, #153, #14, #31, and #176); failed to ensure staff performed hand hygiene when providing care for one resident (#143); and, failed to ensure enhanced barrier precautions were followed for one resident (#115). The deficient practice could lead to spread of infection.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that medications were administered within ordered parameters and in accordance with accepted standards of practice for one of five sampled residents (Resident #10) who were found to have unnecessary medications. The deficient practice had the potential to cause adverse drug effects and place residents at risk for harm from unnecessary medication that was not clinically indicated at the time of administration.

Based on observation, interview, review of clinical record, and review of facility policy and procedure, facility failed to ensure that residents with an atypical rash received appropriate treatment, isolation, and infection control measures for 24 residents (#155, #36, #50, #185, #186, #41, #51, #53, #54, #55, #85, #188, #99, #180, #189, #106, #9, #123, #190, #150, #153, #14, #31, and #176); failed to ensure staff performed hand hygiene when providing care for one resident (#143); and, failed to ensure enhanced barrier precautions were followed for one resident (#115). The deficient practice could lead to spread of infection.